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Case Presentation – Bruce Slater
May 25, 2005
Visit 1) Early 20-s female graduate student in horticulture at UW/Madison who presented to
resident clinic last fall with 8 month history of abdominal pain.
February 2004 Abdo pain started while sleeping on hid-a-bed at parents house. Pain was located
in LUQ-LU Flank. It was described as an “ache” and further as she “wishes she could grab it and
pull or push it away.” She rates the pain 6/10, constant, worse after big meal, makes her feel like
she “cannot take full breath”, worse after sitting, worse when hungry, eating sometimes helps.
She denies N,V, diarrhea, constipation. No relation to urination, but describes stronger than usual
odor to urine recently. There has been no change with menses. BUT she does get significant
menstrual cramps lower in abdomen. One episode of heavy drinking made it worse. Takes no
medications for the pain.
In May 2004 she acquired health insurance and visited Dean Urgent Care. She was told it was
muscle pain. She had PT, massage, which felt good but didn’t help pain. She tried a Chiropractor
and was pain free for 3 weeks followed by return of same pain. Starting September had episodes
of “spreading numbness” in abdomen, no radiation or numbness in legs, lasting 30 minutes,
relieved on it’s own. PMH 2 pregnancies miscarried. SH non-smoker. Drinks 8x/mo 3-4 beers
each time. Smokes marijuana daily for 6 years. History of using hallucinogenic drugs most
recently in 1998. Monogamous with husband +/- condoms. Meds – Tylenol prn h/a FH parents
50’s negative ROS – vaginal discharge
Exam – NAD, VS nl, tender left paraspinous muscles, not CVA, left abdomenal pain lateral to
rectus muscles plus LLQ. No masses or organs. Negative rebound. Pelvic exam moderately
tender to cervical motion, due to tenderness left adnexal fullness could not be ruled out on exam.
Plan: symptomatic treatment for musculoskeletal pain
plus Cervical Motion Tenderness presumed PID treatment and cultures f/u 1 week
Visit 2) 2 weeks later, (newly revealed) low back and LLQ improved and discharge resolved.
LUQ abdominal pain improved for 3 days then recurred suddenly. Feeling of fullness after eating,
Pain worsens with position. Exam – NAD. Abdomen soft, tender to palpation in LUQ, 2cm
movable mass, moves under rib cage. Labs – GC Chlamydia neg, UA/UC neg, P: r/o spigelian
hernia, upper abdominal US renal US
Visit 3) 4 days later walked in sobbing with 8-9/10 LUQ pain after bike ride. “feels that
something terrible is wrong”, “my color is off”, “afraid I am seriously ill”
Exam crying, anxious, unable to sit still. Positive left post thoracic rib cage pain, negative for
acute abdomen, “fullness in LUQ”, stat CT abdomen negative. P: r/o hernia, consider possible
splenic flexure syndrome
Visit 4) Returns 1 week later. LUQ Pain continues 4-5 in am 8-10/10 during day, unbearable by
evening. New periumbilical pain, new RLQ achy deep pain unaffected by GI, positional changes.
Has had dysparunia for some months (not previously reported). Went off wheat which increased
stools (not decreased!), and she noticed changes in the consistency of stools to having white hard
grit in them.
Visit 5) Seen by Dr. Starling who diagnosed “floating rib syndrome”
Visit 6) Pain described as shifting occurring more peri-umbilical, down to RLQ, “worried about
pain” does not like to take meds, uses herbal remedies. Has been reading on web and wonders if
she has “dysmemorrhea”
Exam – “Anxious but calm”, not depressed. Costovertebral angle “exaggerated” tenderness.
There were no trigger points and no spinal tenderness. 12th rib left is painful, but not does not
reproduce her pain. Abdo diffuse tenderness. Periumbilical tenderness. No LUQ tenderness.
Pelvic no CMT, but bilateral adnexal tenderness, and uterus tender.
Plan : consider spigelian hernia, endometriosis unlikely, low grade ovarian torsion, cyst other
ovarian pathology, unlikely IBD, could be IBS, refer GYN then GI and CXR.
Visit 7) 1 mo later, pain resolved somewhat on new grain and dairy free diet some LUQ sporadic
pain, but feeling better than she has in a while. Immediate recurrence of symptoms with
thanksgiving dinner, resolved when previous diet resumed. Since improvement is concerned
about “smoldering appendicitis” and now has RLQ pain, occasionally sharp, few seconds, wax
and wane, several days without pain. Now LLQ pain occurs with menses. Patient has new
symptom – swelling of lip.
Exam – erythema over middle of upper lip consistent with early labial herpes.
Visit 8) GYN visit, LUQ pain resolved. Persistence bilateral lower abdominal pelvic pain for 6
months 6/10 not previously noted to other examiners. Typical Mittlesmertz ovulatory symptoms
now last the rest of cycle. Pain resolves with menstrual flow. History of accident where husband
fell on her abdomen with his shoulder, not previously mentioned. Now relates no dysmenorrheal
symptoms. PH wellbutrin clonazepam for anxiety at age 19. Exam – declines pelvic exam (didn’t
like GYN) Treatment discussed, declined BCP and low dose antidepressant. Suggested NSAIDs
and expectant treatment.
Visit 9) 4 months later – in tears. Diffuse abdominal and midepigastric constant pain not related
to anything. Pain recurred even though on non-wheat diet, vomited when anxious. Has decreased
appetite, feels “something” in abdomen that moves around. Has been reading on Internet and
feels like it is endometriosis. But no longer related to menstrual cycles. Willing to consider
surgery. Exam 130 lbs –diffuse mild tenderness, palpable aortic pulsation. P: therapeutic trial of
dicyclomine,
Visit 10) 10 days later taking dicyclomine, decrease in sharp abdominal pain, now “low
abdominal ache more noticeable due to improvement in sharp pain.” Had blurred vision and
urinary retention with dicyclomine. Asking about stronger pain medications.
Exam mild diffuse abdominal pain less intense while patient is talking.
P: try to move up second opinion GYN appt. Nurse was unable to change appointment, spoke
with patient, she states she will “try to finish her courses this semester and deal with the pain after
the end of classes” as previously scheduled.
Visit 11 and procedure) Saw GYN surgeon – who discussed other options, but patient wanted
diagnostic surgery. Diagnostic laposcopy was done and results completely normal.
Visit 12) Continues to have pain and sensation of hard ball in stomach. Relates vicodin given for
post-op pain completely relieved post-op pain, but did not touch original symptom. P: Reassured
no masses, diseases or cancer found in abdomen. Discussed GI referral but suggested OTC
omeprazole, explore alternative treatment for anxiety, supportive amateur psychotherapy, try to
resume usual activities. Follow-up in 2 weeks. … To be continued …